Data Cart

Your data extract

U.S. Department of Commerce Economics and Statistics Administration U.S. Census Bureau

Please complete this form and return it as soon as possible after receiving it in the mail. This form asks for information about the people who are living or staying at the address on the mailing label and about the house, apartment, or mobile home located at the address on the mailing label. If you need help or have questions about completing this form, please call 1-800-354-7271.

For more information about the American Community Survey, visit our web site at: http://www.census.gov/acs/www/.

Start Here:

Please print today's date: ______

Month: _____Day: _______Year: _______

Please print the name and telephone number of the person who is filling out this form. We may contact you if there is a question.

Last Name: ___________First Name: ___________MI: __

Area Code + Number: ______________

How many people are living or staying at this address?

Include everyone who is living or staying here for more than 2 months.

Include yourself if you are living here for more than 2 months.

Include anyone else staying here who does not have another place to stay, even if they are here for 2 months or less.

Do not include anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

Number of people: ____

Fill out pages 2, 3, and 4 for everyone, including yourself, who is living or staying at this address for more than 2 months. Then complete the rest of the form.

Person 1 is the person living or staying here in whose name this house or apartment is owned, being bought, or rented. If there is no such person, start with the name of any adult living or staying here.

Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

1. Which best describes this building? Include all apartments, flats, etc., even if vacant.

[] A mobile home [] A one-family house detached from any other house [] A one-family house attached to one or more houses [] A building with 2 apartments [] A building with 3 or 4 apartments [] A building with 5 to 9 apartments [] A building with 10 to 19 apartments [] A building with 20-49 apartments [] A building with 50 or more apartments [] Boat, RV, van, etc.

b) How many of these rooms are bedrooms?
Count as bedrooms those rooms you would list if this house, apartment, or mobile home were for sale or rent. If this is an efficiency/studio apartment, print "0".

Number of bedrooms: ___

8. Does this house, apartment, or mobile home have:

a) Hot and cold running water?

[] Yes[] No

b) A flush toilet?

[] Yes[] No

c) A bathtub or shower?

[] Yes [] No

d) A sink with a faucet?

[] Yes[] No

e) A stove or range?

[] Yes [] No

f) A refrigerator?

[] Yes [] No

g) Telephone service from which you can both make and receive calls? Include cell phones.

[] Yes[] No

9. How many automobiles, vans, and trucks of one-ton capacity or less are kept at home for use by members of this household?

[] None [] 1 [] 2 [] 3 [] 4 [] 5 [] 6 or more

10. Which fuel is used most for heating this house, apartment or mobile home?

11. a) Last month, what was the cost of electricity for this house, apartment, or mobile home? Last month's cost Dollars $________________.00 or

[] Included in rent or condominium fee [] No charge or electricity not used

b) Last month, what was the cost of gas for this house, apartment or mobile home? Last month's cost Dollars $________________.00 or

[] Included in rent or condominium fee [] Included in electricity payment entered above [] No charge or gas not used

c) In the past twelve months, what was the cost of water and sewer for this house, apartment, or mobile home? If you have listed here less than 12 months, estimate the cost. Past 12 months' cost
Dollars $________________.00 or

[] Included in rent or condominium fee [] No charge

d) In the past twelve months, what was the cost of oil, coal, kerosene, wood, etc., for this house, apartment, or mobile home? If you have lived here less than 12 months, estimate the cost Past 12 month's cost Dollars $________________.00 or

[] Included in rent or condominium fee [] No charge or these fuels not used

12. In the past twelve months, did anyone in this household receive food stamps or a food stamp benefit card? Include government benefits from the Supplemental Nutrition Assistance Program (SNAP). Do not include WIC or the National School Lunch Program.

[] Yes [] No

13. Is this house, apartment, or mobile home part of a condominium?

[] Yes [] No

What is the monthly condominium fee? For renters, answer only if you pay the condominium fee in addition to your rent; otherwise, mark the "None" box. Monthly Amount Dollars $________________.00 or [] None

14. Is this house, apartment, or mobile home Mark (X) one box.

[] Owned by you or someone in this household with a mortgage or loan? Include home equity loans. [] Owned by you or someone in this household free and clear (without a mortgage or loan)? [] Rented [] Occupied without payment of rent? Skip to C

Section B

Answer questions 15a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 16.

15. a) What is the monthly rent for this house, apartment, or mobile home? Monthly amount Dollars $____.00

b) Does this monthly rent include any meals?

[] Yes [] No

Section C

Answer questions 16-20 If you or someone else in this household owns or is buying this house, apartment, or mobile home. Otherwise, skip to section E on the next page.

16. About how much do you think this house and lot, apartment, or mobile home (and lot, if owned) would sell for if it were for sale? Amount Dollars $____.00

17. What are the annual real estate taxes on THIS property? Annual amount Dollars $____.00 or

[] None

18. What is the annual payment for fire, hazard, and flood insurance on THIS property? Annual amount Dollars $____.00 or

[] None

19. a) Do you or any member of this household have a mortgage, deed of trust, contract to purchase, or similar debt on this property?

[] Yes, mortgage, deed of trust, or similar debt [] Yes, contract to purchase [] No skip to question 23a

b) How much is the regular monthly mortgage payment on this property? Include payments only on FIRST mortgage or contract to purchase Monthly amount - Dollars $____.00 or

[] No regular payment required -> skip to question 23a

c) Does the regular monthly mortgage payment include payments for real estate taxes on this property?

b) How much is the regular monthly payment on all second or junior mortgages and all home equity loans on this property? Monthly amount - Dollars $____.00 or

[] No regular payment required

Section DAnswer question 24 if this is a mobile home. Otherwise, skip to Section E.

21. What are the total annual costs for personal property taxes, site rent, registration fees, and license fees on THIS mobile home and its site? Exclude real estate taxes. Annual costs - Dollars $____.00

Section EAnswer questions about person 1 on the next page if you listed at least one person on page 2. Otherwise, skip to page 28 for the mailing instructions.

Person 1 [This form repeats for each person listed]

Please copy the name of Person 1 from Page 2, and then continue answering questions below.

Last Name ____ First Name ____ MI _

7. Where was this person born?

[] In the United States - Print name of state. ____ [] Outside the United States - Print name of foreign country, or Puerto Rico, Guam, etc. ____

8. Is this person a citizen of the United States?

[] Yes, born in the United States -> skip to 10a [] Yes, born in Puerto Rico, Guam, the U.S. Virgin Islands, or Northern Marianas [] Yes, born abroad of U.S. citizen parent or parents [] Yes, U.S. citizen by naturalization. Print year of naturalization: ____ [] No, not a U.S. citizen

9. When did this person come to live in the United States? Print numbers in boxes. Year: ____

10. a) At any time in the last three months, has this person attended school or college? Include only nursery or preschool, kindergarten, elementary school, home school, and schooling which leads to a high school diploma or a college degree.

[] No, has not attended in the last 3 months -> skip to question 11. [] Yes, public school, public college [] Yes, private school, private college, home school

[] Person is under 1 year old -> skip to question 16. [] Yes, this house -> skip to question 16 [] No, outside the United States and Puerto Rico - Print name of foreign country, or U.S. Virgin Islands, Guam, etc., below; then skip to question 16. ____ [] No, different house in the United States or Puerto Rico

b) Where did this person live 1 year ago?

Address (Number and street name) ____ Name of city, town, or post office ____ Name or U.S. county or municipio in Puerto Rico ____Name of U.S. state or Puerto Rico zip code ____

16. Is this person currently covered by any of the following types of health insurance or health coverage plans? Mark "Yes" or "No" for each type of coverage in items a - h. Yes No

a) Insurance through a current or former employer or union (of this person or another family member)

[] Yes [] No

b) Insurance purchased directly from an insurance company (by this person or another family member)

[] Yes [] No

c) Medicare, for people 65 and older, or people with certain disabilities

[] Yes [] No

d) Medicaid, Medical Assistance, or any kind of government- assistance plan for those with low incomes or a disability

[] Yes [] No

e) TRICARE or other military health care

[] Yes [] No

f) VA (including those who have ever used or enrolled for VA health care)

[] Yes [] No

g) Indian Health Service

[] Yes [] No

h) Any other type of health insurance or health coverage plan

[] Yes, specify: ____ [] No

17. a) Is this person deaf or does he/she have serious difficulty hearing?

[] Yes [] No

b) Is this person blind or does he/she have serious difficulty seeing even when wearing glasses?

[] Yes [] No

Section GAnswer question 18a-c if this person is 5 years old or over. Otherwise, skip to the questions for person 2 on page 12.

18. a) Because of a physical, mental, or emotional condition, does this person have serious difficulty concentrating, remembering, or making decisions?

[] Yes [] No

b) Does this person have serious difficulty walking or climbing stairs?

[ ] Yes [ ] No

c) Does this person have difficulty dressing or bathing?

[] Yes[] No

Section HAnswer question 19 if this person is 15 years old or over. Otherwise, skip to the questions for Person 2 on page 12.

19. Because of a physical, mental, or emotional condition, does this person have difficulty doing errands alone such as visiting a doctor's office or shopping?

[] Yes [] No

20. What is this person's marital status?

[] Now married [] Widowed [] Divorced [] Separated[] Never married, skip to Section I

21. In the past 12 months did this person get

a) Married?

[] Yes[] No

b) Widowed?

[] Yes [] No

c) Divorced?

[] Yes [] No

22. How many times has this person been married?

[] Once [] Two times [] Three or more times

23. In what year did this person last get married? Year: _____

Section IAnswer question 24 if this person is female and 15-50 years old. Otherwise, skip to question 25a.

24. Has this person given birth to any children in the past 12 months?

[] Yes [] No

25. a) Does this person have any of his/her own grandchildren under the age of 18 living in this house or apartment?

[] Yes [] No, skip to question

25. b) Is this grandparent currently responsible for most of the basic needs of any grandchild(ren) under the age of 18 who live(s) in this house or apartment?

[] Yes [] No, skip to question

25 c) How long has this grandparent been responsible for the(se) grandchild(ren)? If the grandparent is financially responsible for more than one grandchild, answer the question for the grandchild for whom the grandparent has been responsible for the longest period of time.

[] Less than 6 months [] 6 to 11 months [] 1 or 2 years [] 3 or 4 years [] 5 or more years

26. Has this person ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training for the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf War.

[] Yes, now on active duty [] Yes, on active duty during the last 12 months, but not now [] Yes, on active duty in past, but not during the last 12 months [] No, training for Reserves or National Guard only skip to question 28a [] No, never served in the military ->skip to question 29a

27. When did this person serve on active duty in the U.S. Armed Forces? Mark (X) a box for each period in which this person served.

[] September 2001 or later [] August 1990 to August 2001 (including Persian Gulf War) [] September 1980 to July 1990 [] May 1975 to August 1980 [] Vietnam era (August 1964 to April 1975) [] March 1961 to July 1964 [] February 1955 to February 1961 [] Korean War (June 1950 to January 1955) [] January 1947 to June 1950 [] World War II (December 1941 to December 1946) [] November 1941 or earlier 28.

28. a) Does this person have a VA service-connected disability rating?

29. a) Last week, did this person work for pay at a job (or business)?

[] Yes, skip to question 30 [] No, did not work (or retired)

b) Last week, did this person do any work for pay, even for as little as one hour?

[] Yes [] No, skip to question 35a

30. At what location did this person work last week? If this person worked at more than one location, print where he or she worked most last week.
a) Address (Number and street name) ____
If the exact address is not known, give a description of the location such as the building name or the nearest street or intersection.
b) Name of city, town, or post office ____

c) Is the work location inside the limits of that city or town?

[] Yes [] No, outside the city/town limits

d) Name of county ____
e) Name of U.S. state or foreign country ____
f) ZIP Code: ____

31. How did this person usually get to work last week? If this person usually used more than one method of transportation during the trip, mark (X) the box of the one used for most of the distance

During the past 12 months (52 weeks), in the weeks worked, how many hours did this person usually work each week? Usual hours worked each week: _____

Section LAnswer questions 41-46 if this person worked in the past 5 years. Otherwise, skip to question 47.

41-46 Current or more recent job activity.

Describe clearly this person's chief job activity or business last week. If this person had more than one job, describe the one at which this person worked the most hours. If this person had no job or business last week, give information for his/her last job or business.

41. Was this person... Mark (X) ONE box

[] an employee of a private for profit company or business, or of an individual, for wages, salary, or commissions? [] an employee of a private not for profit, tax-exempt, or charitable organization? [] a local government employee (city, county, etc.)? [] a state government employee? [] a federal government employee? [] Self-employed in own not incorporated business, professional practice, or farm? [] Self-employed in own incorporated business, professional practice, or farm? [] Working without pay in family business or farm

42. For whom did this person work? If now on active duty in the armed forces, mark (X) this box -> [ ] and print the branch of the Armed Forces Name of company, business, or other employer ____

43. What kind of business or industry was this? Describe the activity at the location where employed. (For example: hospital, newspaper publishing, mail order house, auto engine manufacturing, bank) ____

47. Income in the past 12 months. Mark (X) the "Yes" box for each type of income this person received and give your best estimate of the total amount during the past 12 months. (Note: The "past 12 months" is the period from today's date one year ago up through today.) Mark (X) the "No" box to show types of income not received. If net income was a loss, mark the "Loss" box to the right of the dollar amount. For income received jointly, report the appropriate share for each person or, if that's not possible, report the whole amount for only one person and mark the "No" box for the other person.

a) Wages, salary, commissions, bonuses, or tips from all jobs. Report amount before deductions for taxes, bonds, dues, or other items

[] Yes $____.00 (Total amount for past 12 months) [] No

b) Self-employment income from own nonfarm businesses or farm businesses, including proprietorships and partnerships. Report net income after business expenses

[] Yes $____.00 (Total amount for past 12 months) [] No [] Loss

c) Interest, dividends, net rental income, royalty income, or income from estates and trusts. Report even small amounts credited to an account

[] Yes $____.00 (Total amount for past 12 months) [] No [] Loss

d) Social Security or Railroad Retirement

[] Yes $____.00 (Total amount for past 12 months) [] No

e) Supplemental Security Income (SSI)

[] Yes $____.00 (Total amount for past 12 months) [] No

f) Any public assistance or welfare payments from the state or local welfare office.

[] Yes $____.00 (Total amount for past 12 months) [ ] No

g) Retirement, survivor, or disability pensions. Do not include Social Security.

[] Yes $____.00 (Total amount for past 12 months) [] No

h) Any such other sources of income received regularly such as Veterans' (VA) payments, unemployment compensation, child support or alimony. Do not include lump sum payments such as money from an inheritance or the sale of a home

[] Yes $____.00 (Total amount for past 12 months) [] No

48. What was this person's total income during the past 12 months? Add entries in questions 47a to 47h; subtract any losses. If net income was a loss, enter the amount and mark (X) the "Loss" box next to the dollar amount.

[] None or $____.00 (Total amount for past 12 months) [] Loss

Continue with the questions for Person 2 on the next page. If only 1 person is listed on page 2, skip to page 28 for mailing instructions.

[The document repeats the above "person" form for up to five residents]